North Central Health Advisory Board (4th DRAFT)



North Central Health Advisory Board

Community Assessment Survey (2002)

Your input is important and will be used to develop plans to improve the quality of life of our community. All information provided will be kept CONFIDENTIAL.

Quality of Life Statements

Rate the quality of life statements. (circle one number)

Ratings are (1) = very dissatisfied, (2) = dissatisfied, (3) = satisfied, (4) = very satisfied

1. You are satisfied with the quality of life in your community. 1 2 3 4

(Consider your sense of safety, well being, and participation in

community life and associations, etc)

2. You are satisfied with the health care system in the community. 1 2 3 4

(Consider access, cost, availability, quality, options in health care, etc.)

3. This community is a good place to raise children. 1 2 3 4

(Consider school quality, day care, after school programs recreation, etc.)

4. This community is a good place to grow old? 1 2 3 4

(Consider elder-friendly housing, transportation to medical services, churches,

shopping, elder day care, social support for the elderly living alone,

meals on wheels)

5. There is economic opportunity in the community. 1 2 3 4

(Consider locally owned and operated businesses, jobs with career growth,

job training/ higher education opportunities, affordable housing, reasonable

commute, etc.)

6. The community is a safe place to live. 1 2 3 4

(Consider resident’s perceptions of safety in the home, the workplace,

schools playgrounds, parks, the mall. Do neighbors know and trust

one another? Do they look out for one another?)

7. You are satisfied with church and faith community outreach in the community. 1 2 3 4

8. Individuals and groups have the opportunity to contribute to and participate 1 2 3 4

in the community’s quality of life.

9. Residents can perceive that they can individually and can collectively make 1 2 3 4

the community a better place to live.

(Consider community clean-ups, block watches, helping a neighbor)

10. You are satisfied with contribution made by businesses, agencies, and 1 2 3 4

organizations to build community assets. (Consider parks, schools, churches)

11. You are satisfied with levels of mutual trust and respect between community 1 2 3 4

partners. (Consider government, schools, churches, voluntary agencies)?

12. You are satisfied that there is a sense of community responsibility for 1 2 3 4

building community pride.

Health Care Questions

1. How do you describe your health status? (circle one): good fair poor

2. Where do you usually go when you are sick or need health care? (check all that apply)

___Doctors office ___Community Health Center

___Public Health Clinic ___Hospital Emergency Department

___Hospital Outpatient Department ___Other (Please specify):______________

3. In the past 12 months, was there a time when you needed health care but did not seek it?

___Yes, I needed medical care, but did not seek it.

___No, there has not been such an occasion

3a. If you answered yes to 3., what was the reason you did not seek health care?_____________________________

4. What do you feel are barriers to getting health care in your community? (check all that apply):

___Too much paper work ___Location of healthcare/no transportation

___Cost ___No doctor/staff speak my language

___Fear or distrust of health care system ___Other (please specifies):_____________

___Prescription or medicine cost

5. Where do you get information about health resources available in your community? (check all that apply)

___School ___Church ____Neighbors ___Family ___TV ___Newspaper

___Community Service Organizations (Please specify):______________________________________

___Other (Please specify):_____________________________________________________________

6. Do you smoke? (check one) ___Yes ____No 6a. Does someone else in the house smoke? ___Yes ___No

7. Do you drink alcohol? (check one) ___seldom ___daily ___never

8. Have you been diagnosed by a doctor with any of the following: (check all that apply):

___Diabetes ___High Blood Pressure ___Cancer ____Dental Health problems

___Stroke ___Heart Disease ___Asthma ____Lung Disease

___Sinus Problems ___Sickle Cell Anemia ___Infant death ____Obesity

___Epilepsy ___Kidney Disease ___Liver Disease ____Drug abuse/addiction

___Alcohol abuse ___Mental Disorders ___Gonorrhea ____Migraine Headaches

___Eye Disorders ___Hearing Disorders ___HIV/AIDS ____Hepatitis

___TB ___Lupus ___Arthritis ____Family Violence

___Memory Loss ___Glaucoma ___Stress

___Lack of Pregnancy Care ___Respiratory disease

9. If you or member of your household was diagnosed by a doctor with any of these diseases please answer the following questions:

9a. Cancer

1) What type?______________________________________________

2) When diagnosed? ________________________________________

3) Does anyone in your family have or had cancer? ___Yes ___No____________(relationship)

4) Do you or members of your household receive treatment for cancer? ___Yes ___No

5) Has anyone in your household died from cancer? ____Yes _____When? ___No

9b. High Blood Pressure

1) When diagnosed?_________________________________________________________

2) Does anyone in your family have high blood pressure ___Yes ____No __________(relationship)

3) Do you or members of your household take medicine daily for your high blood pressure? ___Yes ___No

4) Do you check your blood pressure daily? ___Yes ___No

5) Has anyone in your household died from high blood pressure? ___Yes ______When ___No

9c. Diabetes (Sugar)

1) When diagnosed?________________________________________________

2) Does anyone in your family have diabetes (sugar)? ___Yes ____No_____________(relationship)

3) Do you or members of your household take medicine daily for you diabetes (sugar)? ___Yes ___No

4) Has anyone in your household died from diabetes (sugar) ___Yes _____When? ___No

9d. Lung or Respiratory Disease

1) When diagnosed?_____________________

2) What type of lung or respiratory disease? (asthma, emphysema, sinuses, bronchitis, etc)_____________________________

3) Does anyone in your family have lung or respiratory disease? ___Yes ___No ______________(relationship)

4) Do you or members of your household take medicine for your lung or respiratory disease?

___Yes ___No

5) Has anyone in your household died from lung or respiratory disease? ___Yes ____When? ___No

9e. Heart Disease

1) When diagnosed? ________________________________

2) What type of heart disease? (coronary heart disease, cardiovascular disease, congestive heart failure, enlarged heart etc.) ____________________________________________________

3) Does anyone in your family have heart disease? ___Yes ___No ___________________(relationship)

4) Do you or members of your household take medicine for heart disease? ___Yes ___No

5) Has anyone in your household died from heart disease? ___Yes ____When? ____No

9f. Stroke

1) When diagnosed?____________________________________________

2) Has anyone in your family had a stroke? _____Yes ____No ____________(relationship)

3) Do you or members of your household take medicine for your stroke? ___No ___Yes

4) Has anyone in your household died from a stroke? ___Yes ___When? ___No

9g. Homicide

1) Has any member of your household been a victim of a homicide? ___Yes ___No

2) Has anyone in your family been a victim of a homicide? ___Yes ___No

Demographic Information

1. Male________ Female________

2. Age:_________

3. Married___ Single ___ Divorce ___ Widow ___

4. Race:________________________

5. Registered Voter: _____Yes ______No

6. Employed:______Full-time ____Part-time ___Unemployed ___Retired ___Self-Employed

7. Highest Education Level Attained (check one):

Less than High School____ High School (9-12)_____ College Courses____

College Graduate ____ Vocational Training _____ Graduate School____

8. Household Income: (check one) Under $10,000____ $10,000-$19,999____

$20,000-$29,999___ $30,000-$39,999____ $40,000-$50,000____ Over $51,000____

9. How many people does this income support?____ 9a. # of children ( ................
................

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